Whenuakite Country Kids Early Childhood Education Centre
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3Whenuakite Country Kids
Early Childhood Education Centre
Childs Details
Surname
Given Names
Date of Birth
Boy/Girl
Ethnicity
Iwi
Home Address
Home Phone
Guardians Details
Mothers Name
Fathers Name
Home Address
Home Address
Home Phone
Home Phone
Work Address
Work Address
Work Phone
Work Phone
Mobile
Mobile
E-mail
E-mail
I authorise the following person/s to collect my child: (apart from parents as above)
Name
Relationship to the child
Name
Relationship to the child
Name
Relationship to the child
Names of people who are forbidden by law to have access to the child or have access with conditions
Legal papers copied and filed. Yes/ No
EMERGENCY CONTACT DETAILS (if Parents are un-contactable)
Person's name:
Address:
Phone number:
Relationship to child:
HEALTH INFORMATION
Doctors Name:
Phone Number:
Information concerning Health/Medication/ Allergies etc
Immunisation Certificate sighted
Y/N
Please bring Well Child Immunisation Certificate
for copy to keep on file
Please bring Birth Certificate OR Passport for copy
Official Identification Sighted
Y/N
to keep on file
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Parent category: Business